MENTOR APPLICATION

Personal Information:
Name___________________________________________________________ Gender ___ Male
First
Middle
Last
___ Female
Address ______________________________________________________________________________
Street
City
State
ZIP
Home phone ___________________________ Mobile phone __________________________________
Name/address of employer _______________________________________________________________
Work phone ___________________________ Occupation ____________________________________
E-mail address ________________________________________________________________________

Volunteer Information:
1. Indicate your grade preference:

_____Elementary
_____Jr. High/Middle School
_____High School
_____Technical School
_____College Students

2. What do you feel are the strengths (bilingual, math skills, previous relevant volunteer experience, etc.)
you can bring to this program?
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
3. Write a brief statement on why you have chosen to participate in the mentor program.
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
4. Please check initial each line acknowledging that you have read and understand the commitment to
become a mentor, in order to continue to the application
_____I understand and meet the applicant pre-requisites requirements
_____I have read what it takes to become a mentor and understand I must complete the application and
interview process for consideration to be a mentor
_____I understand Dreamers Reality reserves the right to refuse any volunteer applicant and suspend or
terminate any volunteer at any time if it is discovered that they made false statements during the
application process or at any time during their commitment they violate Dreamers Reality Policies and
Procedures.
5. Educational Background (mark all that applies):
___ Some high school

____Graduate/professional school

___High school graduate

____Technical school
___Some college
____College graduate
____ (please specify) _________________________________________________________
6. Why do you want to become a mentor? ___________________________________________________
_____________________________________________________________________________________
7. Please list three references (please include at least one family member, one personal friend and one
work reference):
Name __________________________
Phone number ___________________
Relationship ____________________
Years Known____________________

Name __________________________
Phone number ___________________
Relationship _____________________
Years Known_____________________

Name __________________________
Years Known ________________________
Phone number ___________________
Relationship ____________________
I certify to the best of my ability that the information provided on this application is true and accurate. I
also understand that misinformation knowingly provided here, and on subsequent mentor application
forms, is grounds for dismissal.
_________________________________

Signature

_________________________________

Date

More Information:
3. Do you prefer working with a particular grade level (approximate ages in parentheses)? Please indicate
which.

4. Do you prefer working with a ___ Girl ____Boy

____No Preference

5. Do you prefer working with a quiet, reserved child?

____Yes ____No ____ No Preference

6. Do you prefer working with an outgoing child? ____ Yes

____ No ____ No Preference

8. Do you speak a foreign language? ___________ If yes, please specify: ________

9. Please list any hobbies or interests you may have:___________________________________________
_____________________________________________________________________________________
10. What would you like to do with a mentee? _______________________________________________
11. What clubs or groups, if any, do you belong to? ___________________________________________
_____________________________________________________________________________________
12. My favorite subject in school was ______________________________________________________
13. My least favorite subject in school was __________________________________________________
14. Please put an X by the activities you enjoy the most:
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___

Playing sports such as ____________________________________________________________

Watching sports such as __________________________________________________________
Writing
Reading
Listening to music such as ________________________________________________________
Photography
Attending plays
Going to the movies
Arts and crafts
Visiting zoos and parks
Visiting museums
Using computers
Playing games
Cooking
Exploring possible careers
Hiking and seeing nature
Other _________________________________________________________________________

15. What qualities would you like in a mentee? ______________________________________________

16. What individual has served as a role model for you? Why? _________________________________
_____________________________________________________________________________________
17. If you could recommend one book for your mentee to read, what would it be?

_____________________________________________________________________________________

Adapted from materials provided by Mentoring Partnership of Long Island, The ABCs of Mentoring, and California
Governors Mentoring Partnership.